Tag, you’re it!
By Warren R. Heymann, MD, FAAD
Sept. 28, 2022
Vol. 4, No. 39
Chances are you will see a patient with skin tags today.
Patients will likely ask you two questions: Why do I get them? What do you mean my insurance won’t cover their removal (for asymptomatic lesions)?
This commentary will focus on run-of-the-mill, workaday, ho-hum skin tags (aka acrochordons, fibroepithelial polyps [FEPs]). Yes, acrochordons can accompany syndromes such as the Birt-Hogg-Dubé syndrome; “skin tags” may be basal cell carcinomas in the nevoid basal cell carcinoma syndrome; fibroepithelioma of Pinkus may present like a polyp; and dermatosis papulosa nigra, polypoid seborrheic keratoses, and verrucae may all be “tags.” (1) Those disorders will not be discussed in this editorial.
FEPs appear in up to 60% of the adult general population, equally affecting men and women. Skin tags are more common in patients with diabetes, obesity, metabolic syndrome, and a family history of FEPs. They have been observed increasingly in children and adolescents, correlating with the epidemic of obesity in the young. Acrochordons mostly affect flexural areas (neck, axillae, inguinal region) and eyelids. Lesions are usually just a few millimeters in size, but may be significantly larger, up to 2 cm. (2) The number of lesions may range from a few to dozens. They are usually asymptomatic. FEPs can easily become irritated by friction, trauma from jewelry or seat belts, and may be painful if infarcted. In my experience, the most common “irritation” is emotional — people are annoyed by the presence of these pesky lesions.
Reassurance that these are benign lesions may be all that is necessary for some patients. If patients are obese, with or without associated acanthosis nigricans, a polite reminder of the importance of a healthy diet and exercise regimen is worthwhile. (If FEPs are what motivates patients to change their ways, God bless acrochordons!) Lesions may be removed by scissor snip excisions, shave excisions (for larger lesions, where lidocaine may be warranted), cryosurgery, or light electrodessication for tiny lesions. (1) The “cryosnip” technique — freezing the base of the FEP with liquid nitrogen, followed by scissor removal, may obviate the need for needle-delivered local anesthesia. (3) Patients will ask if they can remove tags themselves at home by tying a string around the base like their grandma used to do, or by over the counter caustic agents. While I’m sure these techniques may work — I do not recommend them. A word about biopsies — not every skin tag requires histopathologic confirmation. If any particular lesion is in question, of course biopsy it. If you are performing biopsies on FEPs, please only put one specimen in a bottle. Every so often, one of the lesions you removed may surprise you — think about how you would approach the patient who had a dozen lesions removed where 11 were FEPs and one was a polypoid melanoma. Good luck.
Histologically, a classical skin tag has an unremarkable epidermis, or appear verrucous or seborrheic keratosis-like. A fibrovascular stroma is at the core. Their etiology is unknown but is probably influenced by multiple factors. Genetics plays an important role. Aoki et al performed whole-exome sequencing of 8 skin tags and target-exome sequencing of 4 skin tags form a 54-year-old woman with multiple lesions and a positive family history of FEPs. They found a single mutation in FGFR3, HRAS, or KRAS in each skin tag, all of which are recurrent causative mutations in seborrheic keratoses (SKs). None of the mutations were identified in her peripheral blood leukocytes, meaning that these were somatic mutations. The authors then investigated 32 skin tags from additional 10 patients, in whom 9 had sporadic FEPs. They identified a single lesion specific mutation in FGFR3, HRAS, KRAS, or EGFR. The authors hypothesize that the location of the lesions — neck and axillae — influenced these driver mutations to cause an FEP phenotype rather than SKs. (4) Hormonal factors may be at play — insulin-like growth factor-1 (5), androgen and estrogen receptors (6), leptin (7), and thyroid hormone receptors (8) have all been implicated in the pathogenesis of FEPs. The role of human papilloma viruses (HPVs), which has been associated with FEPs in multiple studies, requires further scrutiny. (9)
When I was finishing my residency in 1983, Leavitt et al published the following which caused a brouhaha: “The relation between adenomatous colonic polyps and the development of adenocarcinoma of the colon is well established. An association between skin tags and colonic polyps in patients with acromegaly has also been reported. To ascertain if skin tags are a cutaneous marker for colonic polyps independent of the presence of acromegaly, 100 men referred for colonoscopy were studied. Forty-six patients had colonic polyps and 37 also had skin tags; the correlation was highly significant (p less than 0.005). The sensitivity and specificity of the presence of skin tags serving as a cutaneous marker for adenomatous colonic polyps were both greater than 75%. Thus, at least in this population, skin tags may serve as a means for identifying patients at increased risk for having colonic polyps.” (10) After a flurry of controversy, it was realized that there is no direct correlation between FEPs and colonic polyps. I thought this was settled long ago, but this topic still shows up in the literature. I completely concur with conclusion of Zaki et al, who recently performed colonoscopy on the 12 patients with heme-positive stools (6%) out of 200 patients with FEPs: “The mere presence of skin tags does not significantly correlate with existence of colonic polyps and does not justify screening colonoscopy unless other metabolic, GIT [gastrointestinal], and biochemical markers are identified.” (11)
In conclusion, FEPs are part of daily dermatological practice. Mostly they are a cosmetic issue, but they may be symptomatic, and can be treated (if so desired) with a variety of techniques. One day — hopefully not for quite a while — I will retire. When that day arrives, there is so much I will miss about my patient encounters. Discussions about insurance coverage for skin tag removal will be an exception.
Point to Remember: Skin tags are mostly of cosmetic concern, but they may be symptomatic, warranting their removal. Their etiology is unknown, but genetics, metabolic, hormonal, and mechanical factors are all contributory.
Our expert’s viewpoint
Jules B. Lipoff, MD, FAAD
Clinical Associate Professor (Adjunct)
Lewis Katz School of Medicine, Temple University
I always want to maximize my impact in any patient’s life and quality of life, no matter how small the issue may seem, and helping patients with skin tags is no exception. In my experience, skin tags may be thought of as supposedly minor problems, but they may simply be symptoms that will get patients into your office when they might not have sought attention for what might be more significant underlying issues. Since many acrochordons are associated with obesity, examining skin tags can potentially be a point of entry into conversation to gently open discussion and help the patient reflect upon their lifestyle including diet and exercise. I think many physicians are afraid to bring these topics up, and of course we don’t want to pathologize normal variations in weight or to lecture patients, but we shouldn’t miss these opportunities to make a connection and a difference for our patients.
If we call fibroepithelial polyps merely a “cosmetic issue,” I think it may do them a disservice. FEPs may be yet another cutaneous manifestation of systemic disease that we as dermatologists are the best trained and suited to diagnose and appreciate the greater implications. We are on the front lines with especially our younger healthier patients who can benefit the most from early interventions.
Belgam Syed SY, Lipoff JB, Chatterjee K. Acrochordon. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28846244.
Pandey A, Sonthalia S. Skin Tags. 2021 Aug 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 31613504.
Farshchian M, Kimyai-Asadi A, Daveluy S. Cryosnip for skin tag removal. J Am Acad Dermatol. 2021 May 30:S0190-9622(21)01032-X. doi: 10.1016/j.jaad.2021.05.039. Epub ahead of print. PMID: 34062213.
Aoki S, Hirata Y, Kawai T, Nakabayashi K, Hata K, Suzuki H, Kosaki K, Amagai M, Kubo A. Frequent FGFR3 and Ras Gene Mutations in Skin Tags or Acrochordons. J Invest Dermatol. 2021 Nov;141(11):2756-2760.e8. doi: 10.1016/j.jid.2021.03.028. Epub 2021 Apr 30. PMID: 33940034.
Farag AGA, Abdu Allah AMK, El-Rebey HS, Mohamed Ibraheem KI, Mohamed ASED, Labeeb AZ, Elgazzar AE, Haggag MM. Role of insulin-like growth factor-1 in skin tags: a clinical, genetic and immunohistochemical study in a sample of Egyptian patients. Clin Cosmet Investig Dermatol. 2019 Apr 26;12:255-266. doi: 10.2147/CCID.S192964. PMID: 31118729; PMCID: PMC6503204.
Bakry OA, Samaka RM, Shoeib MA, Maher A. Immunolocalization of androgen receptor and estrogen receptors in skin tags. Ultrastruct Pathol. 2014 Oct;38(5):344-57. doi: 10.3109/01913123.2014.911788. Epub 2014 May 15. PMID: 24830664.
Seleit I, Bakry OA, Samaka RM, Samy M. Immunohistochemical Evaluation of Leptin Role in Skin Tags. Ultrastruct Pathol. 2015;39(4):235-44. doi: 10.3109/01913123.2015.1006744. Epub 2015 Apr 10. PMID: 25860907.
Di Cicco E, Moran C, Visser WE, Nappi A, Schoenmakers E, Todd P, Lyons G, Dattani M, Ambrosio R, Parisi S, Salvatore D, Chatterjee K, Dentice M. Germ Line Mutations in the Thyroid Hormone Receptor Alpha Gene Predispose to Cutaneous Tags and Melanocytic Nevi. Thyroid. 2021 Jul;31(7):1114-1126. doi: 10.1089/thy.2020.0391. Epub 2021 Mar 13. PMID: 33509032; PMCID: PMC8290313.
Dianzani C, Paolini F, Conforti C, Silvestre M, Flagiello F, Venuti A. Human papillomavirus in skin tags: a case series. Dermatol Pract Concept. 2018 Oct 31;8(4):295-296. doi: 10.5826/dpc.0804a08. PMID: 30479858; PMCID: PMC6246066.
Leavitt J, Klein I, Kendricks F, Gavaler J, VanThiel DH. Skin tags: a cutaneous marker for colonic polyps. Ann Intern Med. 1983 Jun;98(6):928-30. doi: 10.7326/0003-4819-98-6-928. PMID: 6859706.
Zaki AM, Elshahed AR, Diab MR, Hasan MS, Elsaie ML. Prevalence and predictors of colon polyps in patients with skin tags: A cross sectional study. J Cosmet Dermatol. 2021 May 19. doi: 10.1111/jocd.14240. Epub ahead of print. PMID: 34008290.
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